SIU 2018: BPH Panel: Enucleation Techniques: Holmium

Seoul, South-Korea ( Endoscopic enucleation of prostate adenoma for the treatment of benign prostate hyperplasia (BPH) has been endorsed by the European Association of Urology (EAU) guidelines.  Holmium laser enucleation of the prostate (HOLEP) is one of several enucleation techniques available today on the market.

The efficacy of this procedure has been shown to be very high. This is due to the short hospital stay associated with it, the short catheter time, the amount of tissue that can be removed, the relatively short procedure time, the low transfusion rate, the possibility to use this modality for any sized prostate, and the very encouraging outcomes, demonstrating high urinary flow,  dramatic change in IPSS and a sustained reduction in PSA. When compared to other enucleation modalities, HOLEP has been shown to be at least as efficient, if not more efficient than the other modalities.

In a meta-analysis of 23 randomized controlled trials including 2245 patients, comparing HOLEP to the green light laser, open prostatectomy, and monopolar and bipolar TURP, HOLEP was shown to be more effective than TURP and was demonstrated to be very time efficient procedure.1

Dr. Kumar has invented a laser bridge to minimize the bouncing of the laser fiber during the procedure. This bridge also prevents any thermal damage to the scope. Dr. Kumar supports not using any locking device, which enables total freedom of movement which makes it more versatile, even in large glands.

The technique Dr. Kumar uses entails first making an incision at the 6 o’clock, starting at the bladder neck. He then widens the bladder neck and incises proximal to the verumontanum. Next, he develops the floor and defines the distal limit, proximal to the external sphincter at 12 o’clock. The second incision is performed at the 12 o’clock at the bladder neck, and then the bladder neck is widened. The roof is developed, and the left lobe at 3 o’clock is removed, and then the right lobe at 9 o’clock is removed. The last stage is morcellation of the removed tissue. With this technique Dr. Kumar has removed very large prostate adenomas, reaching a size of 634 gram!

HOLEP has been demonstrated to be effective and safe in very large prostates2 and for recurrent post-TURP residual tissue or recurrent symptomatic BPH.3 Additionally, there is promising data on the positive outcomes of HOLEP in patients with detrusor underactivity4, and even for deroofing severe and multiloculated prostatic abscess.5

Long-term follow-up (10 years) for patients who underwent HOLEP shows a low IPSS score, and a high urinary flow rate with a reoperation rate of between 0-0.7%, and a stricture rate of between 2.4-2.6%. This procedure can be performed when patients are taking low molecular weight heparin, or aspirin without any bleeding issues. Furthermore, the operation is safe in high-risk patients, with high cardiac risk, renal failure, post renal transplantation, post radiotherapy, and brachytherapy. Transient stress urinary incontinence occurs in approximately 2-3% of patients three weeks following surgery but goes down to 0.5% three months following it.

The possible complications include capsular perforation, blood transfusion, bladder injury, urinary tract infection, urge and stress urinary incontinence, reoperation, and stricture. There is no TUR syndrome like in monopolar TURP, and the reported stricture rates are around 1.5%.

Dr. Kumar concluded his talk explaining that surgical proficiency is acquired after a mean of 20 cases6, and the level of an expert is reached after 50 cases. When assessing patient satisfaction, it is repeatedly shown to be very high. All this taken together, make HOLEP a very attractive therapeutic choice.

Presented by: Anil Kumar Varshney, New Delhi, India

1. Ahyal et al. Euro Urol 2010
2. Kim M et al. KJU 2015
3. Shah H et al. J. Urol 2017
4. Woon MJ et al. INJ 2017
5. Lee CH et al. KJU 2015
6. El Hakim and Elhilali et al. BJU Int. 2002

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea